See reply by Hung and Kuo and article by Kuo et al

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Smoking and Suicide Mortality Risk in Alcohol-Dependent Individuals

To the Editor: Hung et al1 recently reported their findings on the risk and protective factors for suicide mortality among persons with alcohol dependence in a nested case-control study. They identified in the literature a number of factors demonstrated to be associated with suicide mortality, such as gender, continued drinking, mood disorders, hopelessness, history of suicidal behaviors, interpersonal difficulties, and social disadvantage. Variables were collected by retrospective chart reviews. The authors found 2 risk factors (auditory hallucination, prior suicide attempt) and 3 protective factors (financial independence, being married, physical illness) for suicide mortality. Unfortunately, Hung et al1 neglected to consider tobacco smoking as a possible risk factor for suicide.

Prevalence of tobacco smoking among individuals in treatment for alcohol use disorder is as high as 75%2 and is characterized by heavy smoking.3 First demonstrated in 1976 by Doll and Peto,4 the robust association between smoking and suicide mortality has been established5 and is dose-dependent, with an estimated increase in risk of suicidal death of 24% for each increment of 10 cigarettes smoked per day.5 Although the underlying mechanism of the greater suicide risk in smokers is not currently fully elucidated,6 the statistical association has been shown to withstand adjustments for psychiatric and substance use–related confounding factors,7 and more specifically alcohol use.8–10 We suspect that smoking may have been poorly documented in the medical records of cases and controls, leading to the omission of this major confounder from Hung and colleagues’ data analysis.1

Although we recognize the importance of this study in drawing attention to the elevated risk of suicide among persons with alcohol dependence, we regret that it missed disentangling the contributions of tobacco smoking and alcohol dependence to the increased suicide risk in this population. We would like to emphasize the importance of systematically documenting smoking behavior in medical records of individuals with psychiatric and addictive disorders, because tobacco smoking can be considered as an aggravating condition not only among individuals with alcohol dependence,11,12 but also more widely among individuals with a psychiatric condition.13,14

References

1. Hung GC-L, Cheng CT, Jhong JR, et al. Risk and protective factors for suicide mortality among patients with alcohol dependence. J Clin Psychiatry. 2015;76(12):1687–1693. PubMed doi:10.4088/JCP.15m09825

2. Guydish J, Passalacqua E, Pagano A, et al. An international systematic review of smoking prevalence in addiction treatment. Addiction. 2016;111(2):220–230. PubMed doi:10.1111/add.13099

3. Aubin HJ, Laureaux C, Zerah F, et al. Joint influence of alcohol, tobacco, and coffee on biological markers of heavy drinking in alcoholics. Biol Psychiatry. 1998;44(7):638–643. PubMed

4. Doll R, Peto R. Mortality in relation to smoking: 20 years’ observations on male British doctors. BMJ. 1976;2(6051):1525–1536. PubMed doi:10.1136/bmj.2.6051.1525

5. Li D, Yang X, Ge Z, et al. Cigarette smoking and risk of completed suicide: a meta-analysis of prospective cohort studies. J Psychiatr Res. 2012;46(10):1257–1266. PubMed doi:10.1016/j.jpsychires.2012.03.013

6. Aubin HJ, Berlin I, Reynaud M. Current smoking, hypoxia, and suicide. Am J Psychiatry. 2011;168(3):326–327, author reply 327. PubMed doi:10.1176/appi.ajp.2010.10101501

7. Bohnert KM, Ilgen MA, McCarthy JF, et al. Tobacco use disorder and the risk of suicide mortality. Addiction. 2014;109(1):155–162. PubMed doi:10.1111/add.12381

8. Iwasaki M, Akechi T, Uchitomi Y, et al; Japan Public Health Center-based Prospective Study on Cancer and Cardiovascular Disease (JPHC study) Group. Cigarette smoking and completed suicide among middle-aged men: a population-based cohort study in Japan. Ann Epidemiol. 2005;15(4):286–292. PubMed doi:10.1016/j.annepidem.2004.08.011

9. Miller M, Hemenway D, Bell NS, et al. Cigarette smoking and suicide: a prospective study of 300,000 male active-duty Army soldiers. Am J Epidemiol. 2000;151(11):1060–1063. PubMed doi:10.1093/oxfordjournals.aje.a010148

10. Tanskanen A, Tuomilehto J, Viinamäki H, et al. Smoking and the risk of suicide. Acta Psychiatr Scand. 2000;101(3):243–245. PubMed doi:10.1046/j.0902-4441.2000.ap9s003.x

11. Sarsour K, Johnston JA, Milton DR, et al. Factors predicting change in frequency of heavy drinking days among alcohol-dependent participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Alcohol Alcohol. 2012;47(4):443–450. PubMed doi:10.1093/alcalc/ags036

12. Reitzel LR, Nguyen N, Eischen S, et al. Is smoking cessation associated with worse comorbid substance use outcomes among homeless adults? Addiction. 2014;109(12):2098–2104. PubMed doi:10.1111/add.12688

13. Gurillo P, Jauhar S, Murray RM, et al. Does tobacco use cause psychosis? systematic review and meta-analysis. Lancet Psychiatry. 2015;2(8):718–725. PubMed doi:10.1016/S2215-0366(15)00152-2

14. Callaghan RC, Veldhuizen S, Jeysingh T, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014;48(1):102–110. PubMed doi:10.1016/j.jpsychires.2013.09.014

Henri-Jean Aubin, MD, PhDa,b

henri-jean.aubin@aphp.fr

Amandine Luquiens, MD, PhDa,b

Ivan Berlin, MD, PhDa,c

aUniversité Paris-Saclay, University Paris-Sud, UVSQ, CESP, INSERM, Villejuif, France

bAssistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Villejuif, France

cAP-HP, Hôpital Pitié-Salpêtrière, University Pierre and Marie Curie, Paris, France

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(7):e906

dx.doi.org/10.4088/JCP.16lr10669

© Copyright 2016 Physicians Postgraduate Press, Inc.